How do you greet your patient? Are you a GIVER? By Tamala S. Bradham, Ph.D.

In a recent blog “Discharge, Adios, Goodbye, Thank you for seeing me…”, I shared some insight on the discharge or “thank you, goodbye” practice that can improve patient care.  What about when you first meet a patient?  How do you greet your patients for the first time?  Or on return visits?  How do you greet the family members or significant others that accompany the patient?  Quint Studer (2003) recommends using A-I-D-E-T. AIDET stands for the following: 

Acknowledge “You are important.” Make eye contact, shakes hand, acknowledge everyone in the room, ask or make a relationship-building question/statement (e.g., “your shirt says ‘University of South Carolina’, I went to school there.”). 

Introduce “You are in good hands.” Tell the patient about yourself and mention the referring physician. Example: “Hi! I’m Dr. Tamala Bradham, your audiologist. I want you to know that I’ve worked with more than 500 families who have children who are deaf or hard of hearing during the past 20 years. I see that Dr. Houston referred you to me. We’ve worked together for many years. You’re fortunate to have such an excellent doctor.” 

Duration “I anticipate your concerns.” Tell the patient what to expect (e.g., how long will the test take, what will happen, when will they know the test results, does insurance cover this, etc.). 

Explanation “I want you to be informed and comfortable.” Carefully listens to your patient’s story and use language the patient can understand when describing what will occur during the visit today. 

Thank You “I appreciate the opportunity to care for you.”  Thank the patient for choosing your clinic for services. In closing, asks, “What other questions do you have?”

This is an excellent tool to use, one that I have trained many people to use. 

I, however, want to propose a new tool for consideration.  We need to be a “GIVER” when we meet our patients.

Greet “Greet the patient!”  Make them feel comfortable.  Smile, shake hands, and make eye contact!  Essentially, use your manners!

Introduce “Tell them who you are!”  Let them know your specialty and “mange up” the referring provider.  At the minimum, given them your business card.  Even better, given them a biosketch card with your picture!

Verify “Do you have the right patient?”  The Joint Commission requires that you check for two identifiers to make sure you have the right patient.  Not only should you confirm their name, ask them for their address, date of birth, or ask for a photo id. Patients really want you to do this!

Engage “Let’s talk and listen to one another!”  Patient engagement is central to improving healthcare outcomes.  Listen to what the patient is saying, pause briefly, and then respond to the patient.  Sometimes it is helpful to summarize what the patient said to show that you were an active listener and that you care.  This is also an excellent time to obtain your case history.

Review “Review what will happen during the visit.”  Based on your case history and what the patient shared with you, tell them your plan for that visit and what to expect from you and your practice. 

So what’s the evidence in using GIVER?  First, we should always be respectful and use our manners.  Second, patients who received written information about the provider showed significant improvement on patient satisfaction surveys (Morris et al., 2014).  Third, a Joint Commission safety goal is aimed at improving patient identification to prevent medical errors.  There are has been multiple occurrences where patients have received the wrong care because of not appropriately identifying the correct patient and/or site on the patient.  Furthermore, there are studies that indicate that even with this safety goal (required for hospital accreditation) that we need to do a better job in patient identification (Hennenman et al., 2010; Schulmeister, 2008).  Fourth, studies also suggest that by engaging the patient in their care, there are better outcomes.  With over 1,000 articles in PubMed using “patient engagement” and “outcomes”, while they are not all relevant, it is obvious that this is a hot topic!  Finally, being an active listener and providing an action plan on what will happen during the visit will ultimately help everyone involved.  While not all the patient’s stress will dissipate, it does provide some direction that will help the family navigate often uncharted waters.

When you start to use “GIVER” or “AIDET”, select just one of the letters and do a small test of change.  Over time, gradually add the other letters to your practice.  Find what works for you and the patients you serve. 


Henneman, P. L., Fisher, D. L., Henneman, E. A., Pham, T. A., Campbell, M. M., & Nathanson, B. H. (2010). Patient identification errors are common in a simulated setting. Ann Emerg Med, 55(6), 503-509. doi: 10.1016/j.annemergmed.2009.11.017

Morris, B. J., Richards, J. E., Archer, K. R., Lasater, M., Rabalais, D., Sethi, M. K., & Jahangir, A. A. (2014). Improving patient satisfaction in the orthopaedic trauma population. J Orthop Trauma, 28(4), e80-84. doi: 10.1097/

Schulmeister, L. (2008). Patient misidentification in oncology care. Clin J Oncol Nurs, 12(3), 495-498. doi: 10.1188/08.cjon.495-498

Studer, Q.  (2003).  Hardwiring excellence.  Gulf Breeze, FL:  Fire Starter Publishing.


What’s your salt?  By Tamala S. Bradham, Ph.D.

Since 1175, one of the oldest English proverbs still heard today is “You can lead a horse to water, but you can’t make it drink.”  But, you might not have heard the revised version by Madeline Hunter, a famous American educator.  In a speech, she said “You can lead a horse to water, but you can’t make it drink.  But I say you can salt the oats.”

So, what’s you salt?  How do you motivate people to engage in quality practices?

Motivation is what causes us to take action.  There are numerous theories to explain motivation ranging from instinct theory (inborn pattern of behavior) to humanistic theory (cognitive reasons to do certain behaviors).  So let’s take a simple test:

1)     What gets you up in the morning?
2)     Did you eat breakfast?
3)     Did you brush your teeth?

I know you could answer all the questions but what did you learn?  Hopefully, your answer was something along the lines that you do these things automatically without much thought – it is just what you do.

Let us look at what motivates the people in the healthcare industry.

What motivates the C-suite healthcare executives?  I would guess that they would say that the right care was delivered at the right time…interpretation – met budget and no lawsuits.

What motivates middle management?  Knowing that they are being listened to and that they contribute to decisions being made are key to motivating middle managers.  While the pay check is nice, having the tools and resources to do their job effectively goes a long ways.

What motivates physicians, nurses, and other healthcare professionals and staff?  Motivating the front line staff means that the pay and working conditions are fair and equitable and that they have job security.  Furthermore, they want transparency and flexibility.

Where does quality fall into motivating the people in healthcare?  How do we integrate quality (or salt) into the delivery of healthcare (or oats)?  Remember the answer to the simple test above?  We just do it!  We integrate quality into everything we do so it becomes second nature.  We integrate quality into our

1)     mission and core values,
2)     strategic plan,
3)     data management and benchmarks,
4)     pay structure, and
5)     communication and marketing.

Just like salt, the key in quality is transparency!  You know it is there but you don’t see it.  The right amount makes all the difference in the world.  If you salt it too much or don’t add enough salt, then the outcomes are not as good.  Quality is the same way!

So, what motivates you to integrate quality into your practice?  What is your salt?

A Lesson from My Daughter in Quality Improvement by Tamala Bradham, Ph.D.

Insanity is doing the same thing over and over again but expecting different results (Albert Einstein, n.d.).  In healthcare, evidence strongly suggests that services rendered are not meeting the patients’ needs, are not based on the best scientific knowledge available, and are not provided in an efficient manner that minimizes costs, resources, and time (Berwick & Hackbarth, 2012).  As much as 21 to 47% of healthcare costs may be unnecessary, or even counterproductive, to improved health (Berwick & Hackbarth, 2012).  Many patients, doctors, nurses, and healthcare leaders are concerned that the care delivered is not, essentially, the care that should be received (Institute of Medicine [IOM], 2001).  So why do we keep doing the same thing over and over again?  Why are we so resistant to process improvement?

The answer is change.  When I ask about making a change, I often hear “I don’t have the time”, “There is no money for that”, or “That is not a problem, we are fine just with the way we are doing it”.  Change is hard.  Did you know that there are multiple stages a person can go through when making a change and demonstrating competency?  Here they are:

Unconscious incompetence: The person does not understand or know how to do something.  Furthermore the person does not recognize the shortfall. They may deny the usefulness of the skill.  To move forward, the person has to step outside his or her comfort zone.

Conscious incompetence:  The person does not understand or know how to do something, but he or she does recognize the deficit, as well as the value of adding the new skill in addressing the deficit.

Conscious competence: The person understands or knows how to do something but still needs support and time to demonstrate this new skill or knowledge.

Unconscious competence: The skill or knowledge is “second nature” and can be performed easily. The person can now teach it to others.

Complacency: Beware – This can happen to anyone.  The person becomes too comfortable and only does the same thing over and over again.  In this stage, the person misses opportunities for growth and change.  Not everyone enters this stage but it is worth mentioning.

At any point in time, we could be in all levels because hopefully we all still have things to learn, new skills that we are acquiring, and sharing our knowledge with junior staff.

But what I wanted to know was how do you move from one step to another?  While I can’t take credit for this idea, my daughter was on to something when she shared “BanBossy” with me by the Girls Scouts and LeanIn.Org.  The last step mentioned in “BanBossy” is the thought we feel better about ourselves when we show that we have accomplished something by stepping outside our comfort zones, overcome barriers, and master challenging tasks.  Many people struggle with stepping outside their comfort zones as they worry about making a mistake, what people will think of them, failing, or disappointing others.  We need to be willing to try new things and not worry about perfection.

So what does this have to do about quality improvement – everything!  Really take a look at your practice.  Is there anything that is a barrier to patient access, unnecessary steps in a process, or other supplies you could use that would be less expensive but do the task?  In quality improvement, we should strive to be in the:

Conscious Incompetence exploring new ways to improve;

Conscious Competence perfecting our system and knowledge; and

Reaching outside our Comfort Zone in trying new ways to improve healthcare!


BanBossy.Org. (2014).  Retrieved from

Berwick, D. M., & Hackbarth, A. D. (2012).  Eliminating waste in US health care.  Journal of the American Medical Association, 307(14), 1513-1516. doi: 10.1001/jama.2012.362  (2014).  Conscious competence learning model. Retrieved from

Institute of Medicine [IOM]. (2001).  Crossing the Quality Chasm: A new health system for the 21st century.  Retrieved from

Discharge, Adios, Goodbye, Thank you for seeing me, Take care of yourself: No matter how you say it healthcare providers need to do a better job when the patient leaves their site by Tamala Bradham

Yes, I know that was the longest title ever but I got your attention!  Working in a hospital setting we often hear about discharges.  How many were discharged last month, handovers, discharge summaries, patient’s perception of the discharge are just a few items that are tracked.  In the outpatient world, discharges are just as important.  When the patient leaves your office, do they know what they need to do next? Hospitals and healthcare providers have a responsibility to ensure safety and efficiency when discharging a patient from their care.

Bear with me as I put on my researcher hat, patients are experiencing adverse events following discharge due to delayed or absent communication, inaccuracies in information exchange, and/or ineffective planning or coordination of care between providers (Hesselink, Schoonhoven, et al., 2013; Hesselink, Vernooij-Dassan, et al., 2013 ).  In fact, at least 20% of patients report adverse events following discharge with at least half of these adverse events could have been prevented.

So what is your discharge or “thank you, goodbye” practice?  Here are some 5 take-aways to consider:

1)      Write it down!  Discharge instructions should be written down for patient understanding, not for compliance and insurance companies.  Don’t worry about saving the trees, give the patient the recommendations/plan of care in writing.  And, if you have it available, the patient should be able to review them at any time on your secure, web-based patient portal that you have available.

2)      Since we no longer work in silos, share your instructions/plan of care with the patient’s medical home, therapists, and those that need to know!  Handoffs are one of the biggest problems in patient care that leads to adverse events.

3)      Check for comprehension!  Having the patient repeat back what they heard is essential.  Using techniques like “Teach Back” or motivational interviewing are great ways to check for comprehension.

4)      Make the discharge follow-up phone call!  Multiple studies show that if a simple phone call is made within 48 hours of the patient being seen or discharged from the hospital, it is a win-win for everyone involved.  For outpatients, not only will you keep that person as a patient; you will get more referrals due to having a happy customer.  For hospitals, research shows reduced readmission rates and significant cost savings!

5)      Own the discharge process!  When the patient leaves your practice/hospital, everyone who directly and indirectly touched that patient needs to own the process.  Does the patient know when to return?  Does the patient know who to contact if they have problems?  Will the patient tell a friend about the great experience they had?

Are you already doing these five simple things to keep patients safe?  If not, consider one of these for your next PDSA.


Hesselink, G., Schoonhoven, L., Plas, M., Wollersheim, H., & Vernooij-Dassan, M. (2013).  Quality and safety of hospital discharge:  A study on experiences and perceptions of patients, relatives and care providers.  International Journal for Quality in Health Care, 25(1), 66-74.

Hesselink, G., Vernooij-Dassan, M., Pijnenborg, L., Barach, P., Gademanm, P., Dudzik-Urbaniak, E.,…Wollersheim, H. (2013).  Organizational culture:  An important context for addressing and improving hospital to community patient discharge.  Medical Care, 51(1), 90-98.

For more information about Teach back, visit and!.aspx

For more information about motivational interviewing, visit  or

For more information about discharge phone calls, visit or

Side note:  I do not have any financial interest in any of the items mentioned in this blog.

Documentation Compliance 101: Protect Yourself by Tamala Bradham

In healthcare, after every patient encounter, test ordered and completed, and even phone calls should be documented in the patient’s medical chart. Here are five things you should know that they don’t teach you in school:

1) “What are you trying to hide?”
If your notes are not completed in a timely manner, then be prepared to answer “what are you trying to hide?” or “how many patients did you see that day? how could you remember what to write if you did your note a week later?” Any notes that are placed in the medical chart greater than 24 hours after the patient was seen/contact is subject to concern.

2) “Does it matter that my note was saved on the wrong date?”
Two things to know:
1) If the note is not there on the day of service, then the patient was not seen.
2) If you dropped charges and there is no documentation, then this is considered fraudulent billing and you could be subject to not only losing your license to practice but also significant fines.
Amend the note to the correct date of service! Or better yet, complete your note the day you saw your patient.

3) “What are the basic components that are needed in a clinical note?”
Every note completed should answer these six basic questions (and I give you the answers too):
1) When was this evaluation completed?
• Date and time services were rendered
2) Why are they here?
• History/Background
3) What did you do?
• Procedures performed
4) What did you find?
• Assessment/Interpretation
5) What should be done now?
• Recommendations/Plan
6) Who did this evaluation?
• Signature

4) “Why did you do that?”
Every procedure administered must be justified based on the ”History/Background” section. If audited, then you will need to answer “Why did you perform the tests/procedures administered?” If your answer is “This was how I was taught in graduate school” or “This is the clinic’s protocol”, then you may be in trouble. While standardization is necessary in complex organizations, performing unnecessary tests/procedures creates waste in the healthcare system and could be subject to fraudulent billings.

5) “Who is responsible for documentation and billings?”
While there may be protocols and procedures on how to complete documentation in your healthcare setting that are designed to comply with federal rules and regulations, insurance guidelines for reimbursement, and The Joint Commission guidelines, ultimately the person who saw the patient/client is responsible for what is documented and billed – not the place of business. Know the rules to protect yourself!

Documentation should not be considered additional work but an extension to your patient care activities. Know the rules, don’t over (or under) document, and get it done!

Defining Quality by Tamala Bradham

“The definition of insanity is continuing to do the same thing over and over again and expecting a different result.”  Albert Einstein.

In one year, National Health Care in the Unites States grew 4% to $2.5 trillion (or $2,486 billion to be exact) in 2009 or $8,086 per person.  This accounts for 17.6% of the Gross Domestic Product consumed in the United States.  Medicare spending grew 7.9% to $502.3 billion and Medicaid grew 9% to $373.9 billion in 2009 (CMS, 2011).  The United States has the highest per capita health care costs of any industrialized nation! Increasing costs are reducing access to care and constitute an ever heavier burden on employers and consumers.  Yet as much as 20 to 30 percent of these costs may be unnecessary, or even counterproductive, to improved health (Wennberg, Brownless, Fisher, Skinner, & Weinstein, 2008).

Addressing these unwanted costs is essential in the survival of providing quality health care.  Some argue that implementing quality management programs is costly.  Others would say that poor quality is costly.  There are many definitions and ideas of quality.

According to my old, reliable Webster’s New World Dictionary (Neufeldt & Guralnik, 1988), quality means “any of the features that make something what it is…the degree of excellence which a thing possesses”.

The Centers for Medicare and Medicaid services (CMS, 2008) defines quality as “how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person—and getting the best possible results.”

Taking this a step further, I wanted to define quality of care.

Interestingly, Wikipedia does not define “quality of care”.

So, lets turn to the experts who wrote the infamous “Crossing the quality chasm: A new health system for the 21st century”.  The Institute of Medicine (IOM) states “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 21).  IOM developed six specific aims for improvement which consist of the following:
• Safe: avoiding injuries to patients from the care that is intended to help them.
• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
• Patient-centered: providing care that is respectful of and responsive to ­individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM, 2001).

To further strengthen this definition, the World Health Organization (2006) adopted the above six aims as their working definition of quality of care.

For me, when I think of quality of care, I need a simple definition, sort of like a mission statement – short, succinct, and powerful!  So I turn to Martin Van Buren who said “It is easier to do the job right than explain why you didn’t.”

Portions of this blog came from an article previously published.
Bradham, T.S. (2011, Invited). Quality 101: What every audiologist and speech-language pathologist should know but was afraid to ask. Perspectives in Hearing and Hearing Disorders in Childhood Deafness, ASHA, 4-7.